Provider Demographics
NPI:1043419591
Name:MATHEW, THOMAS K (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:K
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 BERKSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1367
Mailing Address - Country:US
Mailing Address - Phone:517-265-9396
Mailing Address - Fax:517-265-9396
Practice Address - Street 1:1245 BERKSHIRE CT
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1367
Practice Address - Country:US
Practice Address - Phone:517-265-9396
Practice Address - Fax:517-265-9396
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-15
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI032919208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1368616Medicaid
MI3407869482OtherBLUE CROSS AND BLUE SHIEL
MI1368616Medicaid